We selected this topic for a CBR to address inappropriate billing codes submitted by some providers who are using automated devices to conduct sudomotor-function testing to diagnose anatomic nervous system (ANS) disorders. The American Academy of Neurology (AAN) believes physicians should have specialized training and education to perform ANS testing, and that automated devices “omit essential elements of autonomic testing.” For more information about ANS guidelines, see the following AAN web link: Model Coverage Policy – Autonomic Testing.

To choose providers for this CBR, the data team analyzed Medicare Part B claims of providers who billed claims with CPT® code 95923. Reports were then sent to approximately 2,000 providers identified as having different billing practices than their peers. Providers who did not receive CBR letters can review a sample on our website at the link, CBR201703 Sample CBR.

No. Receiving a CBR does not mean you are billing your claims incorrectly. The goal of the CBR report is to allow you to compare your billing to your peers in your state and the nation and to assist you with understanding Medicare coverage and billing guidelines. If you have questions and or concerns about your CBR, you may contact the CBR Support Help Desk by telephone at 1-800-771-4430 or by email at CBRSupport@eglobaltech.com.

No. The CBR is not punitive, and the team does not conduct any audits of medical charts. The CBR is only for informational and educational purposes and allows providers to compare their billing patterns to those of their peers. If interested in resources that may be helpful with setting up an audit process, please visit our CBR website page at the link titled, Self-Audit Help.

Sudomotor-function testing measures the autonomic nerves that control sweating and, therefore, is a useful tool in assessing autonomic nervous system (ANS) disorders. Sudomotor-function testing (CPT® Code 95923) includes one or more of the following:

The ANS is a control system that acts largely unconsciously and regulates bodily functions such as the heart rate, digestion, respiratory rate, pupillary response, urination, and sexual arousal. ANS testing checks for imbalances in the part of the body that controls many "autonomic" or automatic processes. ANS testing categories include:

According to Cahaba’s LCD L34500, “Most autonomic disorders are diagnosed clinically, with laboratory and formal diagnostic testing playing an adjunctive or confirmatory role. Testing may also be appropriate to monitor disease progression when there is a change in clinical status, or to evaluate a patient’s response to specific treatment for an autonomic disorder...ANS testing is directed at establishing a more accurate or definitive diagnosis or contributing to clinically useful and relevant medical decision making.” A list of conditions that would be considered appropriate for ANS testing can be found at the following web link: Cahaba LCD L34500.

The length of time for ANS testing depends on the method used. The American Academy of Neurology (AAN) states testing can take between 90 and 120 minutes when performed under carefully controlled conditions and interpreted by a physician specializing in ANS disorders; however, testing with automated devices performed without physician interpretation can generate results within 10 to 15 minutes. The AAN does not recommend ANS testing using automated devices and is “concerned that erroneous results obtained from devices of unproven scientific validity could adversely impact patient care.” For more information about AAN guidelines, select the following web link: Model Coverage Policy – Autonomic Testing.

ANS testing is allowed once per year to confirm or exclude a specific autonomic disorder. Repeat testing can be done, after confirming the diagnosis, to check for changes in clinical status or to evaluate the patient’s response to therapeutic intervention. Repeat testing should not be done more than once a year. According to National Government Services (NGS) LCD L36236, “Providers who perform these tests on an unusually high proportion of their patients, or at frequencies exceeding once per year may be subject to medical review.” More details on ANS testing are available at the following web link: NGS LCD L36236.

What kind of physician training does Medicare require to administer ANS testing?

Medicare covers ANS testing that is reasonable and necessary when performed by physicians who have appropriate training. According to First Coast Service Options LCD L33609, “Testing must be done for an accepted clinical indication by a properly trained examiner and interpreted by qualified individuals within their scope of practice (weekend courses may not demonstrate expertise). Physicians must have knowledge, training, and expertise to perform and interpret these tests, and to assess and train personnel working with them. This training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program or must reflect extensive continued medical education activities. If these skills have been acquired by way of continued medical education, the courses must be comprehensive, and designated for the American Medical Association (AMA) category I credit by an ACCME (Accreditation Council for Continuing Medical Education) or SMS (State Medical Society) accredited CME provider.” To view more details about physician training, select this web link: First Coast Service Options LCD L33609.

Can automated devices be utilized for sudomotor-function testing (CPT® 95923)?

Equipment utilized for sudomotor-function testing must be approved by the Federal Drug Administration (FDA) and meet general professional standards. Devices with software that automatically interpret ANS results are being marketed to providers; however, AAN’s model policy states: “There are no automated devices currently on the market that, when used alone, are sufficient to bill for autonomic testing using 95921–95924. Billing code 94943 is the only code appropriate for autonomic testing using automated devices.” MACs are reviewing claims more closely to ensure guidelines for ANS tests are being followed. Per Wisconsin Physicians Service (WPS) LCD L35124, “Providers may be asked to supply information on the equipment used to perform autonomic nervous system studies to ensure that all studies performed meet the requirements of the procedure…Testing with ANSAR ANX 3.0 or a similar machine is considered investigational for screening and will not be covered.” More information is available at the following website links:

For this CBR, we selected Medicare Part B claims with CPT® code 95923 (sudomotor-function testing) for services rendered between October 1, 2013 to September 30, 2016. This includes claims that were referred to different rendering providers, as well as self-referrals. The analyses were based on the latest version of claims available from the Integrated Data Repository (IDR) as of February 8, 2017. For information on the IDR, please visit the link titled, CMS Integrated Data Repository (IDR).

Providers were identified by National Provider Identifier (NPI). The peer groups for comparison with the individual provider are listed below:

State: All Medicare providers located in the provider’s state, as determined by the National Plan and Provider Enumeration System (NPPES), who were indicated as referring providers on claims with allowed charges for CPT® code 95923

National: All Medicare providers in the nation, as determined by NPPES, who were indicated as referring providers on claims with allowed charges for CPT® code 95923

Data for the claims reviewed was downloaded from the IDR on February 8, 2017, and loaded into the Palmetto GBA Medicare Data Warehouse. Claims were selected with dates of service rendered between October 1, 2013 and September 30, 2016. For information on the IDR, please visit the link titled, CMS Integrated Data Repository (IDR).

Table 1 is an individual provider’s data and is titled Summary of Your Referrals of CPT® Code 95923. The first column lists the Dates of Service. The other columns provide the Allowed Charges, Allowed Services and distinct Beneficiary Count for the dates of service. For an example, please refer to the mock provider used in the sample CBR. Most of this mock provider’s sudomotor-function tests were referred between October, 2014 and September, 2015. The total allowed charges were $40,890; total allowed services were 231; and the total number of beneficiaries was 179. If you did not receive a CBR and would like to review the mock provider’s, select the following link: CBR201703 Sample CBR.

Table 2 shows the individual provider’s Percentage of Services without Diagnosis Codes that Support Medical Necessity. Based on the data analysis, our sample CBR shows the mock provider’s percentage is 10 percent, which Does Not Exceed the state’s percentage of 34 percent and the national percentage of 22 percent. To view the percentages for each state and the nation, select the following link: CBR201703 Statistical Debriefing.

How is the mock provider’s percentage of services calculated in Table 2?

We calculated the mock provider’s percentage by dividing the Number of Services without Indicated Diagnoses (34) from Table 2 by the Total Number of Services (333) from Table 1, and then multiplied by 100, giving us approximately 10 percent.

Table 3 is the provider’s Percentage of Services Rendered by Providers Who are Not Neurologists. Our sample CBR shows that the mock provider referred 333 services to providers who were not identified as neurologists, which was 100 percent of his/her referrals for sudomotor-function tests. This was Significantly Higher than his/her state’s percentage of 76 percent and the national percentage of 85 percent. The percentages for each state and the nation can be viewed from the following link: CBR201703 Statistical Debriefing.

How is the mock provider’s percentage of services calculated in Table 3?

The percentages were calculated as the Number of Services Rendered by Providers Who are Not Neurologists (333) divided by the Total Number of Services (333), and then multiplied by 100, for a total of 100 percent.

Table 4 is the provider’s Percentage of Beneficiaries Receiving Multiple Services (over 3-year Period). Our sample CBR shows that the mock provider has a total of 55 beneficiaries who received multiple services, which makes up 25 percent of the mock provider’s referrals. This is Higher than his/her state rate of 24 percent, but Significantly Higher than the national rate of 21 percent. To see the percentages for each state and the nation, please visit the CBR website at CBR201703 Statistical Debriefing.

How is the mock provider’s percentage of beneficiaries calculated in Table 4?

The percentage is calculated as the Number of Beneficiaries Receiving Multiple Services (55) from Table 4 divided by the Total Number of Beneficiaries (219) referred from Table 1, and then multiplied by 100. This results in approximately 25 percent.

Table 5 is titled Percentage of a Referring Provider’s Beneficiaries Who Received Sudomotor-Function Testing. In this example, our sample CBR shows that the mock provider referred a total of 219 beneficiaries, which makes up 47 percent of all beneficiaries referred. This is Significantly Higher than the state rate of 4 percent and the national rate of 2 percent. To view results for each state and the nation, select the following link: CBR201703 Statistical Debriefing.

This percentage is calculated as the Number of Beneficiaries Referred Code 95923 divided by the Total of Beneficiaries Referred by Provider for all Medicare Part Be procedure codes, and then multiplied by 100, resulting in approximately 47 percent.